=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073984993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE HAAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2015
-----------------------------------------------------
Last Update Date | 11/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1190 N SHOOP AVE
-----------------------------------------------------
City | WAUSEON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43567-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-335-4601
-----------------------------------------------------
Fax | 419-335-4900
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 351328
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43635-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-335-4600
-----------------------------------------------------
Fax | 419-335-4900
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | LAUREN M HEFNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-866-7162
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 18217
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------